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DENGUE INFECTION

Ardhi Bustami

Department of Internal Medicine

University of Muhammadiyah Malang General Hospital
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Global Burden
Two fifths of the world (2.5 billion people)
population are at risks
• 50-100 million people are infected every
year
• 250,000 people progress to dengue
hemorrhagic fever each year
• 25,000 death each year
• Missing data on non-hospitalised and less
severe cases
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Problems
Leading cause of serious illness and
death among children in some Asian
countries
• Increase incidence of dengue infection
in adult
• Pregnant women are more and more
susceptible
• Intensive mosquito-control programme
resulted in children with non-immune
to dengue
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Clinical manifestation

• Asymptomatic
• Dengue fever
• Dengue hemorrhagic fever
• Dengue shock syndrome
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Dengue fever
• Acute febrile illness with two or more of the
following
– Headache, retro-orbital pain, myalgia,
arthralgia, rash, hemorrhagic manifestation,
leukopenia
• Lab for confirmation
– Isolation of dengue virus, fourfold rising in
reciprocal IgG or IgM, PCR (genomic
sequence), immunostaining (dengue antigen)
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Dengue hemorrhagic fever

• Fever (last 2-7 days), occasionally biphasic
• Hemorrhagic tendency
 Tourniquet test, petechiae, bleeding from mucosa
 Enlargement of the liver (hepatomegaly)
• Thrombocytopenia (< 100,000 cell/mm3)
• Evidence of plasma leakage
– Hct increase >20%, Hct drop >20% after
volume replacement, pleural effusion, ascites,
hypoproteinaemia
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Dengue hemorrhagic fever

Febrile phase
▫ High fever 2-7 days
▫ Facial flushing, skin erythema, myalgia, arthralgia, headache, nausea, vomiting,
sore throat, injected pharynx, conjunctival injection and diarrhea.
▫ Leucopenia, mild thrombocytopenia

Critical phase (Leakage phase)

▫ Heralded by the onset of plasma leakage
▫ Occurs towards the late febrile phase, after 3rd fever, usually 5th – 6th day fever,
last for 24-48 hr

Convalescent phase (recovery phase)

▫ Starts after the end of the critical phase and usually lasts 2-5 days.
▫ Signs of overload (respiratory distress due to pulmonary oedema or
large pleural effusions) if excessive IV fluids in critical phase
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Dengue shock syndrome

•Evidence of circulatory
failure
•Narrow pulse pressure < 20
mmHg
•Hypotension
•Rapid and weak pulse
•Cold, calmy skin, restlessness
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Tourniquet Test
• Fever day 1 50%
• Fever day 2 70%
• Fever day 3 > 90%
False negative TT
• Obese patients
• Thin patients
• Not good technique
• During shock
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Dengue Diagnosis

1. Virus isolation
2. Viral DNA detection by
reverse transcription-PCR
3. Serological test :
ELISA, Rapid test
4. NS-1 Ag
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Early Diagnosis : simple clinical & lab.

• Tourniquet test
PPV = 70-80%
• CBC

Tourniquet test positive + leucopenia* = Dengue infection

*Leucopenia = wbc 5,000 cells/cumm

• At least day 3 of fever

• CBC everyday if possible
• Close follow up until 24 hours of defervescence
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Indications for admission

• Shock
• Platelet 100,000 cells/cumm. c no
good clinical conditions; poor appetite..
 High risk patients: Obese, infants,
bleeding, underlying diseases,
consciousness change
 No care-taker
 Live far away
 Mass-media families
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Warning signs of shock

• Clinical deterioration/ not improve when
no fever/ low
grade fever
• Abdominal pain
• Vomiting
• Restless, shortness of breath, persistent
crying in infants
• Sweating, cold clamy skin
• Behavior change, drowsy
• No urine 4 - 6 hours
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Prolonged shock
• > 10 hours untreated - Death!!!
• > 4 hours untreated
 Liver failure- prognosis 50%
 Liver + Renal failure – prognosis
10%
 3 organs failure (+respiratory
 failure) – Prognosis is a miracle!!!
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A stepwise approach to the management of dengue

 Monitoring of dengue/DHF patients
during the critical period (thrombocytopenia around 100 000 cells/mm3)
• General condition, appetite, vomiting, bleeding and other signs
and symptoms.
• Peripheral perfusion can be performed as frequently as is indicated
because it is an early indicator of shock and is easy and fast to
perform.
• Vital signs such as temperature, pulse rate, respiratory rate and
blood pressure should be checked at least every 2–4 hours in non-
shock patients and 1–2 hours in shock patients.
• Serial haematocrit should be performed at least every four to six
hours in stable cases and should be more frequent in unstable
patients or those with suspected bleeding
• Urine output (amount of urine) should be recorded at least every 8
to 12 hours in uncomplicated cases and on an hourly basis in
patients with profound/prolonged shock or those with fluid
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overload.
Algorithm for fluid management in compensated shock

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Algorithm for fluid management in hypotensive shock

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 Key points – Colloid administration
• In the management of shock after 2 crystalloid boluses if the pulse /BP has not
picked up.
• Development of shock when already having a fluid overload or the amount of
fluid received over a period of time appears to be in the direction of exceeding
M + 5% deficit
• Both dextran 40 and 6% Starch (Hydroxy Ethyl Starch) ar erecommended only
during the critical phase (24 to 48h) of DHF.
• They should only be used as boluses over a maximum period of one hour
(10ml/kg/h) at a time and not as infusions unlike saline
• Dextran may sometimes interfere with grouping and cross matching of blood.
• One could use up to 3 doses of Dextran 40 (each as 10ml/kg/hour) during a 24
hour period (6 doses within 48 hours). 6% Starch (HES) could be given up to 5
doses (each as 10ml/kg/hour) per 24 hours (10 doses within 48 hours).
• A colloid (dextran or 6% Starch) will remain longer than normal salin and FFP

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 Use Packed Red cells (PRC)
• Use PRC at 5ml/kg once and repeat only if
needed.
• 5ml/kg of PRC will increase HCT by 5 points.
(Eg: 30 to 35)
• Even if bleeding is likely and if HCT is >45% do
not give blood without bringing down the HCT
first by giving a colloid.

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Platelet and Fresh Frozen Plasma Transfusion

• Prophylatic transfusions of platelet and FFP is

not recommended
o Platelet transfusions :
required for pts thrombocytopenia who is undergo urgent
surgery, active bleeding which continues in spite of repeated
blood transfusions, DIC or intracranial haemorrhage.
o FFP transfusions :
Dengue pts with hepatic encephalopathy and active bleeding

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 Signs of recovery
• Stable pulse, blood pressure and breathing rate.
• Normal temperature.
• No evidence of external or internal bleeding.
• Return of appetite.
• No vomiting, no abdominal pain.
• Good urinary output.
• Stable haematocrit at baseline level.
• Convalescent confluent petechiae rash or
itching, especially on the extremities.
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Criteria for discharging patients

1. Absence of fever for at least 24 hours without the
use of anti-fever therapy.
2. Return of appetite.
3. Visible clinical improvement.
4. Satisfactory urine output.
5. A minimum of 2–3 days have elapsed after
recovery from shock.
6. No respiratory distress from pleural effusion and
no ascites.
7. Platelet count of more than 50 000/mm3.
 If not, patients can be recommended to avoid traumatic activities for at
least 1–2 weeks for platelet count to become normal
 In most uncomplicated cases, platelet rises to normal within 3–5 days.
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